Whiplash-associated disorders and temporomandibular symptoms following motor-vehicle … ·...

VOLUME 42 • NUMBER 1 • JANUARY 2011 e1

Quintessence international

The association between temporomandibu-

lar symptoms following motor-vehicle col-

lisions and those specifically associated

with whiplash injury has been controversial.

Whiplash-associated disorders are com-

monly associated with motor-vehicle colli-

sions, usually when a vehicle is rear-ended.

Classification of whiplash-associated disor-

ders is shown in Table 1. The Quebec Task

Force on Whiplash-Associated Disorders

defined whiplash as an acceleration-decel-

eration mechanism of energy transfer to

the neck resulting from a rear-end or side-

impact motor-vehicle collision but that may

also occur during diving or other mishaps.

It also indicated the impact may result in

bony or soft tissue injuries, which in turn may

lead to a variety of clinical manifestations

such as whiplash-associated disorders and

include reduced or painful jaw movement.3

These symptoms are associated with tem-

poromandibular disorders (TMDs) and may

present with jaw pain and/or dysfunction in

addition to headache, dizziness, hearing

disturbances, and neck pain or dysfunc-

tion following motor-vehicle collisions.4–12

Furthermore, TMDs may present without

whiplash-associated disorders as sole

independent manifestations due to motor-

vehicle collisions. The superimposition of

these confounding conditions (whiplash-

associated disorders and TMDs) adds to

the difficulty in diagnosis and management.

The purpose of this focused narrative review

is to provide an update, based upon recent

literature, on TMDs associated with or inde-

pendent of whiplash-associated disorders

1 Professor, Department of Oral Medicine and Diagnostic Sciences,

College of Dentistry; and Department of Otolaryngology and

Head and Neck Surgery, College of Medicine, University of

Illinois at Chicago, Chicago, Illinois, USA.

2 Assistant Professor, Department of Oral Medicine and

Diagnostic Sciences, College of Dentistry, University of Illinois

at Chicago, Chicago, Illinois, USA.

Correspondence: Dr Joel B. Epstein, 801 South Paulina Street,

Chicago, IL 60612. Email: [email protected]

Whiplash-associated disorders and temporomandibular symptoms following motor-vehicle collisions Joel B. Epstein, DMD, MSD1/Gary D. Klasser, DMD2

Recent research has shown that temporomandibular symptoms may be associated with or occur independently of whiplash-associated disorders related to motor-vehicle collisions. A PubMed/Medline search was conducted using the terms “temporomandibular disor-ders,” “orofacial pain,” “temporomandibular joint,” “whiplash,” and “whiplash-associated disorders and motor-vehicle accidents and motor-vehicle collisions” for the years 1995 to 2009. Systematic reviews, meta-analyses, and clinical studies were included if they addressed temporomandibular disorders, whiplash epidemiology, diagnosis, and progno-sis. References in the selected articles were also reviewed (including those prior to 1995) if the articles specifically addressed the topic. An evidence base was established for gen-eral outcomes using the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Temporomandibular symptoms may develop following motor-vehicle collisions and be more complex, representing a component of a symptom cluster of potentially regional and widespread pain impacted by psychosocial factors. Oral health care providers must be aware of the relationship between temporomandibular symptoms, whiplash-associated disorders, and trauma and the more complex nature of the symptoms for appropriate diagnosis and management. (Quintessence Int 2011;42:e1–e14)

Key words: motor-vehicle collisions, temporomandibular symptoms and disorders, whiplash-associated disorders

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e2 VOLUME 42 • NUMBER 1 • JANUARY 2011


Epstein/Klasser

resulting from motor-vehicle collisions. Oral

health care providers who have patients

presenting with TMDs following motor-vehi-

cle collision–based trauma should be aware

of the etiology, prognosis, and general prin-

ciples of patient evaluation and manage-

ment, as many of these cases represent a

regional and widespread pain condition.

By understanding the complexity of issues

associated with certain individuals following

motor-vehicle collisions, the clinician should

be better able to provide appropriate man-

agement.

Study SElEction

A PubMed/Medline literature search was

conducted using the terms “temporoman-

dibular disorders,” “orofacial pain,” “tem-

poromandibular joint,” “whiplash,” and

“whiplash-associated disorders and motor-

vehicle accidents and motor-vehicle col-

lisions” (between 1995 and 2009) from

English-language peer-reviewed journals.

The review of articles was limited to the

time frame stated because 1995 is when

the Quebec Task Force monograph was

published, providing the first standard-

ized definition of whiplash-associated dis-

orders. Furthermore, it should be noted

that the Quebec Task Force was unable

to find any published article of method-

ological rigor on this topic published before

1993.3 Systematic reviews, meta-analyses,

and clinical studies were included if they

addressed TMDs, whiplash epidemiology,

diagnosis, and prognosis. In addition, refer-

ences in the articles selected according to

our criteria were also reviewed (including

those prior to 1995) if the articles spe-

cifically addressed the aforementioned four

factors. An evidence base was established

for general outcomes using the Oxford

Centre for Evidence-Based Medicine Levels

of Evidence. In this system, grade A is

the highest level, based upon consistent

evidence for Level 1 studies; grade B

is evidence from Level 2 or 3 studies or

extrapolation from Level 1 studies; and

grade C is from Level 4 studies or extrapo-

lation from Level 2 and 3 studies.

table 1 clinical classification of whiplash-associated disorders1,2

Grade clinical presentation* Subgrade

0 No complaint, no physical signs

1 Neck pain, stiffness, or tenderness

2 Neck complaint and musculoskeletal signs: decreased range of movement and point tenderness

2A: point tenderness, normal range of movement

2B: point tenderness, abnormal range of movement

3 Neck complaint and neurologic signs: decreased or absent deep tendon reflexes, weakness, or sensory deficits

4 Neck complaint and fracture or dislocation

*Deafness, dizziness, tinnitus, headache, memory loss, dysphagia, and temporomandibular pain can appear in all grades.




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EvidEncE for thE prEvalEncE and incidEncE of whiplaSh-aSSociatEd diSordErS and tMdS

Whiplash-associated disorders following

motor-vehicle collisions are estimated to

occur in one-third of all collisions and are

associated primarily with rear-end colli-

sions.13,14 Whiplash-associated disorders

are the most common motor-vehicle injury

treated in emergency rooms in the United

States.15,16 An incidence of 328 visits per

100,000 people were reported in the

United States, and in Canada, whiplash-

associated disorders represented 83% of

accident claims with an annual incidence

of 67 visits per 100,000 people.17,18 In

a Belgian study, 400 consecutive TMD

patients were assessed for jaw injury, and

24.5% of these patients were found to

have had an onset of pain and dysfunc-

tion linked directly to trauma of mainly

whiplash-accident origin.19

The prevalence of TMD symptoms

associated with whiplash-associated dis-

orders was assessed in a population

survey completed at 6 weeks and 4, 8,

and 12 months following the collision.16

Overall, the results indicated that females

had more complaints prior to and follow-

ing collisions. A total of 8,109 claims were

assessed, and 16.4% reported TMDs.

Onset of new TMDs after motor-vehi-

cle collisions was seen in 14.9% (11.6%

male, 17.2% female), while 4.3% reported

TMDs prior to the motor-vehicle collision.

TMDs after collisions were more com-

mon in patients with whiplash-associated

disorders (17.4% [13.2% male, 20.0%

female]) and were reported in 4.7% with-

out whiplash-associated disorders. The

relative risk of TMDs after motor-vehicle

collisions was 3.35 higher in those with

whiplash-associated disorders. Females

had a more than 50% increased risk of

TMDs following motor-vehicle collisions.

Those older than 50 years of age had a

35% increased risk of TMDs. Those who

recalled hitting their head were 40% more

likely to report new jaw pain following the

collision. Patients who reported dyspha-

gia after the injury had a 3.75 relative risk

of TMDs, a relative risk of 2.0 of ringing

in the ears, and a two fold increased risk

of TMDs associated with visual change,

numb arms or hands, dizziness, nau-

sea, increased headache, and neck pain.

Reports of accident parameters (direction

of impact, headrest involvement, seatbelt

use, whether the car was drivable after the

accident) were not associated with risk

of TMDs. Assessment of recovery after

the accident was hampered by 44% par-

ticipation of the 1,128 patients with new

symptoms of TMDs in whom the follow-

up survey found recovery from TMDs in

a median of 120 days; 70% reported no

pain by 4 months, and 78% reported no

pain by 1 year.16

Similar to the above study, 40 consecu-

tive patients with whiplash-associated disor-

ders were compared to 40 control subjects.

The former patients experienced more fre-

quent temporomandibular joint (TMJ) pain

(P < .001), limited jaw opening (P < .01) and

muscle tenderness (P > .01).20 However, the

presence of joint sounds, deviation during

mouth opening, and the overall presence of

a symptom were not significantly different

between groups. Another study assessed

93 patients with whiplash-associated dis-

orders and identified TMDs in 55 of these

(59%); yet, 27 (29%) of those diagnosed

with whiplash-associated disorders were

not diagnosed with TMDs.21 In a recent

narrative literature review of 32 articles that

assessed the possible relationship between

TMDs and whiplash-associated disorders,

it was concluded that a low to moderate

incidence and prevalence of TMDs were

associated with whiplash.22 Based upon

the data, the level of evidence assigned

for the prevalence of whiplash-associated

disorders and TMDs due to motor-vehicle

collisions is grade A.

EvidEncE for thE dElayEd diaGnoSiS and rEcoGnition of tMdS

In a prospective study,23 60 consecutive

whiplash-associated disorder patients fol-

lowing car accidents were compared to

controls in a country in which there is a




Epstein/Klasser

lack of financial compensation from this

type of injury. Patients were examined in

the emergency room and completed a

structured questionnaire. These patients

had neck complaints with or without muscle

findings, did not have cervical fracture

(whiplash-associated disorders grades 1

to 3, see Table 1), and had no loss of

consciousness. Differences in jaw-related

symptoms or function were seen in patients

versus controls at first examination follow-

ing motor-vehicle collisions (12% vs < 5%;

P = .048), and at 1 year follow-up, TMDs

were identified in 33% vs 5% in controls

(P = .004). New symptoms of TMDs were

five times higher in subjects than controls

and higher in females. Fifty-nine patients

were assessed at 1 year (37 female, 22

male), and 19 patients had TMD symptoms

compared to six controls (P = .04). TMDs

were reported as the primary complaint in

5% at the first visit and in 19% (P = .04) at

1 year follow-up with no significant increase

seen in controls at 1 year. These findings

may reflect progression in TMDs and/or

improvement in other symptoms (excluding

TMDs) associated with whiplash-associated

disorders.

TMJ pain began with trauma in 7%,

which was significantly different from the

controls (P = .048), and increased during

follow-up (P = .008) and as compared to

controls (P = .04). Delayed onset of new

symptoms of TMDs was seen in approxi-

mately 33% of whiplash-associated disor-

der patients with TMDs vs 7% of controls

(P < .001, odds ratio ~ 7). Twenty percent

of whiplash-associated disorder patients

reported TMDs as their primary complaint

after 1 year (P = .04). Painful clicking devel-

oped during follow-up in 19% of whiplash-

associated disorder patients, and painful

locking developed in 14% with only one

patient (2%) having TMD symptoms prior

to the accident. Treatment for TMDs was

not provided to study patients or controls

during follow-up, although 12% of patients

who had been involved in motor-vehicle col-

lisions spontaneously requested treatment.

This indicates a significant risk for delayed

onset of TMDs following whiplash trauma,

making this an important consideration for

patient evaluation, diagnosis, prognosis,

management, and medicolegal issues.23

The evidence for delayed onset and/or

delayed recognition of TMDs as a result of

motor-vehicle collisions is grade B.

EvidEncE for rEGional and widESprEad SyMptoMS aSSociatEd with whiplaSh-aSSociatEd diSordErS and tMdS

The literature reports regional and widespread

symptoms associated with whiplash-associat-

ed disorders, including hearing and vestibular

complaints. A recent study assessed 20 whip-

lash-associated disorder patients, 20 con-

trols and 20 patients with acoustic neuroma.

Differences in eye-movement control, postural

stability, smooth pursuit neck torsion test, and

dizziness were seen in whiplash-associated

disorder patients, acoustic neuroma patients,

and controls. A dizziness handicap was similar

in whiplash-associated disorder and acoustic

neuroma patients.24 Mild traumatic brain injury

has also been documented in patients experi-

encing direct impact in addition to a possible

or documented loss of consciousness.15

Grushka et al25 compared 54 post–motor-

vehicle collision patients to 82 nontrauma

TMD patients (control group). Post–motor-

vehicle collision patients reported more

orofacial pain complaints than nontrauma

TMD patients who more commonly reported

jaw joint sounds at the first clinical visit.

Statistically significant differences were seen

between post–motor-vehicle collision patients

and controls in earache (62% vs 44%), ear

stuffiness (48% vs 27%), neck and shoulder

complaints (94% vs 62%), backache (77% vs

42%), numbness or pain in extremities (68%

vs 23%), headache (91% vs 69%), jaw pain

on waking (84% vs 66%), facial pain (93%

vs 69%), poor sleep (86% vs 56%), dizziness

(73% vs 25%), and stress (85% vs 50%) (all

P < .05). Therefore, TMDs post–motor-vehicle

collisions were more commonly associated

with regional pain in the head, neck, and

shoulders, and ear complaints, sleep disor-

ders, and increased stress were more com-

mon, thereby confirming a more widespread

syndrome consistent with regional and central

mechanisms. Widespread pain may nega-




Epstein/Klasser

tively impact prognosis and complicate man-

agement approaches.

In a study10 involving 7,462 patients who

met criteria for whiplash-associated disor-

ders, of whom 45% completed follow-up

surveys, it was found that symptoms com-

monly reported following motor-vehicle colli-

sions included neck and back pain, fatigue,

dizziness, extremity tingling, tinnitus, cog-

nitive problems, paresthesia, headache,

memory and cognition complaints, spinal

pain, nausea, and jaw pain. These common

widespread and diverse symptoms present

a cluster of physical symptoms, suggest-

ing a regional and widespread systemic

disorder and/or possible central changes

that negatively impact prognosis.10 A sup-

portive study assessed experimental pain

in 12 whiplash-associated disorder patients

and controls using intramuscular electrical

stimulation. The repeated electrical stimula-

tion resulted in muscle pain in both groups

with increased sensitivity to stimulation and

larger areas of referred pain in whiplash-

associated disorder patients, suggesting

altered nociceptive input and central pro-

cessing in whiplash-associated disorders.26

In contrast, a prospective but uncontrolled

study of 155 patients assessed by tele-

phone interview reported only one case of

TMD symptoms at 1 year.12

From these reported clinical and exper-

imental studies, grade A evidence was

assigned for regional and widespread

symptoms in relation to symptoms associ-

ated to whiplash-associated disorders and

TMDs following motor-vehicle collisions.

EvidEncE for pSycholoGic SyMptoMS aSSociatEd with whiplaSh-aSSociatEd diSordErS and tMdS

Assessment of depressive symptoms follow-

ing whiplash-associated disorders was con-

ducted in 5,211 subjects.27 New symptoms

of depression were reported in 42% of sub-

jects after 6 weeks and in an additional 18%

at 1 year. Preinjury mental health problems

increased the risk of postinjury depression.

Emotional functioning following mild trau-

matic brain injury was found to be associ-

ated with significantly increased symptom

complaints and global distress compared

to controls.28 Fifty consecutive patients with

whiplash were assessed within 1 week of

injury, at 3 months, and at 2 years and

showed that somatization, insomnia, anxiety,

and depression became abnormal in 81%

of patients after 3 months, remained abnor-

mal in 69% at 2 years, and were elevated in

patients with more severe continuing com-

plaints.29 The clinical status of patients at 2

years was predicted by psychologic scores

and neck symptoms at 3 months, and psy-

chologic changes become established by 3

months. These findings suggest psychologic

changes (including depression) may be part

of a whiplash-associated disorder symptom

cluster.

Regional and central mechanisms,

including sleep disorder, and psychologic

changes may occur as a result of persist-

ing whiplash-associated disorder and is

associated with orofacial pain and symp-

toms of TMD. Therefore, a grade A level of

evidence was attributed to the presentation

of psychologic symptoms associated with

whiplash-associated disorders and TMDs.

EvidEncE for thE principlES of ManaGEMEnt of whiplaSh-aSSociatEd diSordErS and tMdS

The approach to management of TMDs follow-

ing motor-vehicle collisions must be consis-

tent with management of the aforementioned

broader symptoms. Therefore, literature that

discusses management of whiplash-associ-

ated disorders and the more limited studies

on TMD management after motor-vehicle col-

lisons were reviewed.

The general principles of physical

medicine, physical therapy, and directed

medications for musculoskeletal pain and

chronic pain were discussed.4 A population-

based survey of a random sample of 2,000

people from the general adult population

without whiplash-associated disorder was

conducted by mail.30 Pain associated with

whiplash-associated disorders was more




Epstein/Klasser

negative than other noncollision-caused

pain (P < .017) with 55% of whiplash-asso-

ciated disorder patients reporting active

coping (activity and exercise) strategies

as being important for recovery. Whiplash-

associated disorder patients reported

greater pessimism regarding return to usual

activities. Approximately 40% felt symptoms

would not improve quickly, with fewer whip-

lash-associated disorder patients (18%) vs

non–whiplash-associated disorder patients

(32%) expecting symptom resolution (P

= .006). The belief of greater difficulty

and less probability of improvement with

whiplash-associated disorders may affect

management outcome.30

A review of randomized clinical trials of

treatment of adults with whiplash-associat-

ed disorder was published.31 Thirty-six trials

were identified reviewing oral nonsteroidal

anti-inflammatory drugs (NSAIDs), central-

ly acting psychotropic agents, steroids,

and anesthetic agents. For acute whiplash-

associated disorders, prednisone adminis-

tered within hours of injury reduced pain at

1 week, but did not affect pain at 6 months

vs placebo. For chronic symptoms, intra-

muscular lidocaine was superior to placebo

and dry needling and similar to ultrasound.

Muscle relaxants and analgesics had lim-

ited evidence of effect. Myofascial trigger

point injection was found effective, but no

difference using saline or botulinum toxin as

the active agent was reported. A prospec-

tive, controlled study of 37 whiplash-asso-

ciated disorders patients suggested that

botulinum toxin led to improved functional

quality of life.32

In a study33 of 29 whiplash-associated

disorder subjects assessed at baseline and

then randomized to treatment for vestibu-

lar rehabilitation or nontreatment, it was

reported that the intervention group had sta-

tistically significant improvement in physical

and questionnaire assessments. A study

by Klobas et al21 involved 94 consecutive

patients with whiplash-related conditions, of

which 55 had TMDs. These patients were

randomly assigned to a jaw exercise group

(n = 25) or no treatment (n = 30), and no

differences in signs and symptoms of TMDs

were noted at 3- and 6-month follow-up.

The limited studies regarding the man-

agement of TMD symptoms following motor-

vehicle collisons resulted in a grade B level

of evidence. The approach to management

must be consistent with management of the

broader symptoms. Prospective, random-

ized controlled trials of adequate subject

number using appropriate measurement

methodology are needed to enhance knowl-

edge regarding management approaches.

EvidEncE for thE proGnoSiS of whiplaSh-aSSociatEd diSordErS and aSSociatEd tMd SyMptoMS

An understanding of the prognosis of

whiplash-associated disorders is complex

because TMD symptoms may be associ-

ated with whiplash-associated disorders

or present as an independent manifesta-

tion as a result of motor-vehicle collisions.

Regardless, both whiplash-associated dis-

orders and TMDs share a number of com-

mon physical and psychologic features

(Table 2) that greatly influence, either alone

or in combination, the prognosis of these

disorders.

Approximately 15% to 40% of patients

with acute whiplash-associated disorders

that may include TMDs develop chronic

symptoms.34–36 A recent meta-analysis uti-

lizing 14 studies of 11 patient cohorts that

assessed persisting complaints following

whiplash injury identified several risk fac-

tors with strong evidence of predicting pain

after 6 months.37 The risk factors identified

included high baseline neck pain intensity,

presence of headache, high neck disability

(whiplash-associated disorders grade 2 or

3; see Table 1), and no postsecondary

education. Moderate evidence of risk was

identified with catastrophizing, presence of

neck pain, no seatbelt used, neck pain prior

to accident, and being female.37 Another

systematic review found that pain and dis-

ability due to whiplash-associated disorders

decreased rapidly in the first 3 months fol-

lowing motor-vehicle collisions, followed by

little further improvement.18 The prognosis

was affected by high initial pain, high whip-

lash-associated disorder score, anxiety and




Epstein/Klasser

depression, and being female. An earlier

systematic review found age, sex, baseline

neck pain and headache intensity, and the

insurance compensation system to be pre-

dictive of recovery.1 A Delphi (consensus by

a panel of experts) survey to identify factors

that may predict chronic pain and disabil-

ity due to whiplash-associated disorder-

sreported that risk factors for chronic pain

included a history of chronic pain, physical

factors (such as severe injury), and psy-

chologic factors (pain-causing fear, avoid-

ance of exercise, tendency to somatize,

catastrophic thinking, low self-expectations,

and symptoms of post-traumatic stress dis-

order).38 In another study, patients who

reported higher initial pain following motor-

vehicle collisions also reported an increase

in health care utilization.39

It has been hypothesized that females

may be at increased risk of whiplash-asso-

ciated disorders and TMDs due to relatively

less neck mass than males40; however, after

reviewing information from a large data-

base, no relationship with body mass index

was identified.40

A prospective study of 76 patients with

acute whiplash-associated disorders inves-

tigated features that predicted pain and

disability at 6 months after motor-vehicle

collisions.41 Greater physical symptoms

(including loss of neck movement), old age,

hyperalgesia as determined by quantitative

sensory testing, and posttraumatic stress

predicted persistent symptoms. These find-

ings show that both physical and psycho-

logic factors play a role in recovery from

acute whiplash-associated disorders.41 A

prospective study42 designed to identify

prognostic factors for whiplash-associated

disorders up to 12 months after motor-

vehicle collisions enrolled 125 patients who

had mild to moderate whiplash-associated

disorders persisting 2 weeks post–motor-

vehicle collision. Interestingly, 64% of the

patients recovered after 1 year. Neck pain

intensity and work disability were the most

consistent predictors for prognosis. Poor

recovery was more common in females;

those with low education levels; and patients

with high initial pain reports, severe dis-

ability, high somatization, and sleep disor-

ders.42 A systematic review of the literature

that involved 50 articles reporting on 29

cohorts to assess recovery from whiplash-

associated disorders reported that high

initial pain intensity predicted prognosis,

while older females with increased acute

psychologic response involved in rear-end

collisions who were compensated were not

associated with adverse prognosis. Limited

impact upon recovery was seen in those

table 2 physical and psychologic features of whiplash-associated disorders and tMds

physical psychologic

regional widespread affective-motivational cognitive-behavioral

Musculoskeletal disorders Central sensitization Anxiety Memory

Neuropathy Traumatic brain injury Depression Behavior

Inflammation: proinflammatory cytokines

Spinal cord and brain stem injury

Worry Sleep disturbances or dysfunction

Regional pain syndrome Proinflammatory cytokines, pain sensitizers, or pain mediators

Catastrophic thinking

Deconditioning or dysfunction

Temporal and spatial summation Temporal and spatial summation Low self-expectations —

Pain sensitizers or pain mediators Pain sensitizers or pain mediators Fear —

— Sleep disturbances or dysfunction Frustration —

— Fatigue Fatigue —




Epstein/Klasser

with restricted range of motion, a high num-

ber of complaints, and prior psychologic

problems.43

Chronic posttraumatic headache is report-

ed in 30% to 90% of people following mild

head injury with approximately one-third of

those who experienced head injuries reporting

headaches after 6 months and one-quarter

after 4 years.44 Many of these head injuries

may have been the result of motor-vehicle

collisions; however, the incidence of head

injury is difficult to assess, as the majority of

head injuries are mild and not reported; also,

oftentimes, those that are reported are from

heterogenous populations. Regardless of the

etiology, it has been reported that chronic

posttraumatic headache and neck pain arein-

fluenced and perpetuated by physical, social,

cultural, and psychologic/emotional and cog-

nitive factors. Furthermore, high levels of initial

pain were found to predict delayed recovery.44

Other prognostic indicators of whiplash-

associated disorders that have been identi-

fied are related to neck pain 1 year after

injury (reported by 50% of patients) with

greater initial pain, increased number of

symptoms, and greater initial disability pre-

dictive of slower recovery. Additionally, the

direction of collision and headrest type may

be prognostic, and coping style, depressed

mood, and fear of movement were also

associated with slow or limited recovery.45

At a 1-year follow-up, it was reported that

baseline stress response and initial pain

severity were associated with increased

risk of persistent pain, neck disability, and

poorer self-report of general health, and

acute stress reaction was associated with

persisting whiplash-associated disorders.46

Psychologic factors have been reviewed

regarding the prognosis of late whiplash syn-

drome.47 No association was found among

personality traits, distress, well-being, social

support, life control, and psychosocial work

factors. Limited evidence was seen with post-

traumatic distress and chronic symptoms. In a

study involving 275 consecutive chronic whip-

lash-associated disorder patients assessed

by valid questionnaires,48 it was found that

widespread pain in multiple body regions was

associated with pain intensity and prevalence

of complaints and dysfunction. Furthermore,

widespread pain was also associated with

depressive symptoms, coping skills, life sat-

isfaction, and general health complaints. In

other studies,49,50 it was found that depres-

sive symptoms impact pain. Passive coping

was associated with slower recovery, and

pain severity was related to depression, cata-

strophizing, and quality of life. Finally, claim

closure as assessed in 5,398 subjects was

seen earlier in those with less severe pain,

better function, and absence of depressive

symptoms.51

Recognition and management of regional

and widespread symptoms and evaluation of

depression is important in promoting rehabili-

tation of whiplash-associated disorders (level

of evidence grade A), as well as cases of

related orofacial symptoms. The studies of

prognosis of whiplash-associated disorders

and associated TMD symptoms have direct

and important implications related to patient

assessment and management following

motor-vehicle collisions. Therefore, the stud-

ies reviewed have led the authors of this study

to designate a grade A level of evidence for

the prognosis of whiplash-associated disor-

ders and associated TMD symptoms.

EvidEncE for thE proGnoSiS of tMdS followinG Motor-vEhiclE colliSionS

While the literature does not clearly exclude

neck complaints from TMDs, this section

focuses on TMD patients following motor-

vehicle collisions who may or may not have

cervical disorders. As suggested in the pre-

vious section, patients with postinjury TMDs

do not respond as well to treatment as those

involved in nontrauma cases. Patients who do

not recover and return to work prior to settle-

ment of claims appear to continue to have

symptoms.9

Fifty patients with TMDs after motor-

vehicle collisions were compared to 50

matched nontrauma-induced TMD con-

trols.52 Posttrauma TMD patients reported

statistically significantly (P < .001) more

severe facial pain, neck pain, earache, head-

ache, and sleep disturbances. Examination

findings confirmed the history with greater

masticatory muscle, neck muscle, and TMJ

tenderness in the trauma group. In addi-




Epstein/Klasser

tion, greater impact upon work and rec-

reational activities was reported in trauma

patients. In another study using the same

sample, it was reported that posttrauma TMD

patients received more types of treatment (P

< .0001), took more medications (analge-

sics, muscle relaxants, and antidepressants;

all P < .001), had more health care visits

(P = .07), received treatment over longer

periods (P = .06), and had poorer outcomes

(P < .001).53 Another study confirmed that

TMD patients following motor-vehicle colli-

sions show poor response to management

and require more treatment as compared to

nontrauma cases.54 Sixty percent of motor-

vehicle collision cases had symptoms con-

sistent with a depressive disorder vs 14% of

nontrauma cases. Other studies confirm the

poorer prognosis of TMDs in motor-vehicle

collisions.5,25 Mechanisms include sensory

and central hypersensitivity that may result

in both more severe and increased regional

and widespread pain.55,56 One study report-

ed posttrauma TMD patients to have similar

responses to conservative therapy; however,

the posttrauma group required continuing

analgesics, which suggested persistence

of pain.57 Sixteen matched patients with

TMDs associated with and without whiplash-

associated disorders were assessed; trauma

cases were found to be associated with

increased somatization and depression, and

poorer outcomes were seen.58 In an exten-

sive review of the literature, Fernandez et al22

suggested a poorer prognosis for resolution

of TMDs associated with motor-vehicle acci-

dents as compared to idiopathic/nontrau-

matic TMDs. Contrarily, in a clinical report

involving 400 TMD patients, no differences

were found in outcome (pain and dysfunc-

tion) from a conservative treatment (counsel-

ing, occlusal appliance, physical therapy,

and medication) between the trauma and

nontrauma groups at a 1-year evaluation.19

Based upon the reviewed articles, it appears

there is inconsistent but generally a poor

prognosis for the resolution of TMDs (inde-

pendent of whiplash-associated disorders)

following motor-vehicle collisions. Therefore,

a grade A level of evidence was assigned.

Many potential factors may be responsi-

ble for the progression of symptoms moving

from an acute phase to one of chronicity. It

is important for oral health care providers

to understand what these may be so that

appropriate management strategies may be

utilized. Therefore, a review of these poten-

tial factors affecting prognosis of whiplash-

associated disorders and TMDs has been

provided in Table 3.

table 3 potential factors affecting prognosis of chronic whiplash-associated disorders and tMds

history/preexisting conditions physical factors psychologic factors

Prior chronic pain Severity of injury/regional pain (headache, facial, neck, shoulder, back)

Psychosocial stressors, depression, or anxiety

Prior TMDs, headache, neck, and back complaints

Vehicle damage/direction of impact (rear) Somatization

Preexisting systemic conditions (such as arthritis)

Direct facial trauma Catastrophic thinking, low self-expectations

Preexisting psychologic factors Loss of consciousness or traumatic brain injury

Fear, avoidance of exercise (passive coping)

Regional and widespread pain Female Posttraumatic stress disorder

— Body mass index Sleep disorder

— Nature of prior work Social support

— — Medicolegal factors (litigation)




Epstein/Klasser

EvidEncE for thE dirEction of colliSion and proGnoSiS of whiplaSh-aSSociatEd diSordErS and tMdS

Front-end collisions lead to a higher risk of

direct dental and facial injury, while rear-

end collisions are associated with higher

risk of whiplash-associated disorders and

TMDs.59 Poorer outcomes of treatment were

impacted by complaints despite minimal

vehicular damage, lack of use of head-

rest, driver position, and ongoing insurance

claims.

Another study of collision-associated

TMDs in 219 consecutive patients revealed

that reduced maximum jaw opening, head-

ache, and facial pain were associated with

degree of vehicle damage (as represented

by cost of repair), with the greatest limita-

tion in those involved in impacts that result-

ed in write-off of the vehicle. Higher-speed

impact (over 40 mph) was associated with

greater pain (all P < .05).60 Direction of

impact was examined, and facial pain was

more common with rear impact, followed by

front and then side impact (P < .02); head

position at impact (when recalled) showed

that turning to the side was associated with

increased pain.60 A grade B level of evi-

dence was ascribed to collision character-

istics and their impact upon prognosis for

whiplash-associated disorders and TMDs.

EvidEncE rEGardinG thE influEncE of litiGation on thE proGnoSiS of whiplaSh-aSSociatEd diSordErS and tMdS

The impact of ongoing litigation was

assessed in 35 post–motor-vehicle colli-

sion patients and compared to 19 cases

not in litigation.25 Statistically significant

differences were seen in litigating vs non-

litigating patients: earache (72% vs 42%),

TMJ noises (97% vs 65%) (both P < .05),

headache (97% vs 79%), and dizziness

(82% vs 58%) (P < .10). A greater number

of symptomatic complaints were noted by

litigating patients (15 vs 7 for nonlitigating,

P = .004).25 Increased numbers of com-

plaints have been reported by others in liti-

gating patients, whose complaints included

TMDs.61 However, a study62 in Lithuania

assessed TMD symptoms by question-

naire in patients with whiplash (response

rate 79%) an average of 27 (range 14 to

41) months after a rear-end motor-vehicle

collision compared to controls and found

TMDs were not common or comparable

to controls. In addition, this study found

that acute neck symptoms were higher

following motor-vehicle collisions than in

controls and that those symptoms typi-

cally resolved within 4 weeks. The lack of

increased chronic complaints and TMDs

may be attributed to limited compensation

in Lithuania.

Another study interviewed 30 previ-

ously treated patients with TMDs following

motor-vehicle collisions to assess status of

prior symptoms.63 Approximately 75% had

persisting jaw pain, dysfunction, and head-

ache, with more than 80% having neck

pain. Jaw pain was moderate or severe in

56%, headache in 63%, and neck pain in

70%. Jaw pain was improved or resolved

in 65%, headache in 60%, and neck pain

in 50%. Persisting symptoms continued

to have negative impact upon patient-

reported quality of life. No differences

were seen in this study between those who

had settled or had ongoing claims, and

jaw dysfunction and head and neck pain

continued, suggesting ongoing litigation or

settling the claim did not impact the com-

mon persistence of pain and dysfunction.63

Due to the conflicting outcomes of the

impact of litigation upon the prognosis of

whiplash-associated disorders and TMDs,

a grade B level of evidence was allocated

to this subject.

liMitationS of Study

This article should be used judiciously and

within the context of a narrative review with

its inherent limitations. A systematic lit-

erature review or meta-analysis uses a strict

methodology to answer specific research

questions with predefined outcomes,




Epstein/Klasser

whereas a narrative review is employed to

address a broader range of questions and

provides a summary of findings. Although

this article utilized rather general inclusion/

exclusion criteria, formal blinded appraisal

and assessment of studies reviewed was

not administered. The nature of the cur-

rent literature led to inclusion of studies as

per inclusion criteria assigned that did not

include requirements for specific research

designs and specific and designated sta-

tistical approaches and numerical sample

size calculations. Additionally, the literature

review and articles were selected from only

one of several available international scien-

tific literature databases. Upon reviewing

and analyzing the included articles, there

were large variations in the results that may

have been due to variables that included

the heterogeneity of populations studied,

clinical features, or outcomes targeted and

type of data reported. Recognizing these

limitations, a narrative review was conduct-

ed and a standardized grading system was

utilized in producing levels of evidence for

each topic discussed.

concluSion

TMDs have been clearly documented to

follow motor-vehicle collisions; however,

TMDs are identified in only a subset of

whiplash-associated disorder patients or

as an independent finding. TMDs may not

be diagnosed at the time of first assess-

ment, due to the development of symp-

toms at a later date or later recognition of

ongoing dysfunction. TMDs independent

of or associated with whiplash-associated

disorders appear to occur predominantly

in females and may often be accompa-

nied by other regional or widespread pain

that may reflect central, systemic, and

psychologic effects. These findings sug-

gest that multidisciplinary management is

necessary in many patients and that oral

health care providers must consider all

the factors involved using a biopsychoso-

cial approach when managing individu-

als who are experiencing orofacial signs

and symptoms related to motor-vehicle

collisions. To aid oral health care provid-

ers in the management of these complex

individuals, a summary of the features

and findings of the material discussed of

whiplash-associated disorders and TMDs

is presented in Table 4.

table 4 Evidence-based statements of whiplash-associated disorders and tMds following motor-vehicle collisions

Summary statement level of evidence* references

TMDs are associated with whiplash-associated disorders A 10,14,17,18,19,20

Delayed diagnosis of TMDs may occur B 21,34

TMDs are associated with regional and widespread pain

A 8,13,22,24

TMDs and whiplash-associated disorders are associated with psychologic symptoms

A 25,26,27

Management follows principles of physical medicine and psychologic support

B 19,28,29,31

Prognosis of TMDs and whiplash-associated disorders A 16,32,33,34,35,36,37,38,39,40, 41,42,43,44,45,46,47,48,49,50

Prognosis of TMDs following motor-vehicle collisions† A 3,7,20,23,53,55,56,59

Motor-vehicle collision impact characteristics and TMDs B 58,59

Conflicting outcomes of litigation upon outcome of whiplash-associated disorders and TMDs

B 23,60,61,62

*Oxford Centre for Evidence-Based Medicine Levels of Evidence (see text for explanations). †As reported independently of whiplash- associated disorders.




Epstein/Klasser

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